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SIGN-IN SHEET/COMMUNICATION PREFERENCES
PATIENT NAME:_____________________________________ ARRIVAL TIME:_____________
PREFERRED LANGUAGE:_______________________________
PHONE # FOR YOUR DOCTOR OR NURSE TO REACH YOU:___________________________________
PREFERRED PHARMACY ADDRESS & PHONE NUMBER: ____________________________________
_________________________________________________________________________________
E-‐MAIL ADDRESS:___________________________________________________________________
PLEASE CHECK YOUR PREFERRED METHOD OF COMMUNICATION:
______STANDARD MAIL ______E-‐MAIL
______CELL PHONE ______HOME PHONE
PLEASE INDICATE BELOW ANY INDIVIDUALS WITH WHOM WE MAY DISCUSS YOUR MEDICAL
INFORMATION (APPOINTMENTS, TEST RESULTS, ETC.) IF WE ARE UNABLE TO COMMUNICATE
DIRECTLY WITH YOU.
NAME: RELATIONSHIP TO PATIENT
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
RACE: ______________________________________
ETHNICITY:__________________________________
SIGNATURE:_________________________________ DATE:_______________
PLEASE ASK OUR RECEPTIONIST ABOUT OUR PATIENT PORTAL!
1 of 2
PATIENT REGISTRATION FORM Please Print Today’s Date
PATIENT INFORMATION
Full Legal Name (First) (Middle) (Last)
Name Normally Used (Nickname)
Address (Number) (Street) (Apt. No.)
City
State Zip Social Security No. Home Phone
Date of Birth
Age Sex Marital Status Occupation
Employer Name
Employer Street Address City State Zip
Business Phone (Including Extension)
Patient’s Driver’s License No. State
Other Physicians You See
How Did You Hear About Us?
SPOUSE’S INFORMATION
Full Legal Name (First) (Middle) (Last)
Occupation
Address (If Different From Above) City
State Zip Home Phone
Employer Name
Street Address City State Zip Business Phone (Ext)
INSURANCE INFORMATION
Primary Insurance Company Name
Group No. ID/Certificate No.
Subscriber Name
Where to Send Claim
2 of 2
Secondary Insurance Company Name
Group No. ID/Certificate No.
Subscriber Name
Other Insurance Information
EMERGENCY INFORMATION
Person to Notify in Case of Emergency
Relationship
Address (Number) (Street) (Apt. No.)
City
State Zip Home Phone
INFORMATION FOR THE PATIENT
1. Patients who carry standard health insurance should remember that professional services are rendered and charged to the patient and not to the insurance company. All patients with standard health care insurance are expected to make payment as services are rendered, regardless of pending insurance, litigation, etc.
2. Patients with contract health plans should present their insurance ID card to the receptionist after completing this form. Some contract health plans (HMOs, PPOs, IPAs, etc) require a copayment at the time of service. Most contract health plans require that the claim be submitted by our office.
3. If you have any questions we will, of course, be happy to assist you.
CONSENT FOR TREATMENT
1. I consent to any treatment, test or procedure ordered by and given under the supervision
of a physician. (Surgical procedures and anesthesia require additional consent.)
2. I acknowledge that no guarantees have been made as to the results of the hospital care
and medical treatment hereby authorized.
3. I understand that I am fully responsible for all articles (money, radios, jewelry,
dentures, eyeglasses, etc.) and clothing which I retain in my possession (in my room) and
for any other articles and/or clothing which may be brought to me while I am a patient at
Alon Family Health. I understand that Alon Family Health and its associates are not
responsible for loss or damage to any property, which is not turned in for safekeeping.
4. Texas law permits the disclosure of patient health care information without
authorization in certain specific settings, including disclosure for payment purposes,
for continuing care and to an organ procurement organization.
5. I acknowledge that I have been given a copy of the "Patient Rights and
Responsibilities" for review and can request a copy.
6. I acknowledge that I have been given a copy of Alon Family Health’s "Notice of Privacy
Practices" for my review and can request a copy.
7. I acknowledge that I may request the form for Advance Directives from the nursing
staff and/or the physician at any time.
8. The physician's office has my consent to leave telephone and/or text messages at my
home or as otherwise instructed.
9. I acknowledge that Alon Family Health uses e-prescribing to facilitate medication
management for the patient and the patient's medication history will be uploaded
through an RX HUB. I also understand that immunization history will be uploaded
from the Health Department as well as sent to the Health Department via electronic
interface.
10. I acknowledge that I have been given a copy of the "Office Visit Cancellation Policy.”
11. I acknowledge that I have been given a copy of the "Patient Financial Responsibility Policy."
*NOTE: This s t a t e m e n t is to be signed by ALL patients on a yearly basis
at the time of registration. When the patient is a minor. parent or legal guardian
must sign the statement.
WITNESS _ SIGNED _
PATIENT, GUARDIAN, OR LEGAL REPRESENTATIVE
DATE Time
ALON FAMILY HEALTH
PERSONAL HEALTH CONTRACT
Thank you for choosing Alon Family Health for your health care needs. We appreciate the opportunity to care for you and your family. The following information is provided for your benefit so that we may better serve you. Please read and sign at the bottom.
1. Hours of Operation: We are available 8:00 AM-5:00 PM Monday-Thursday and 8:00 AM - 12:00 PM Friday. For after hour emergencies, an on-call physician is available through our answering service or seek immediate care at the nearest Emergency Room.
2. Continuity of Care: Alon Family Health Is able to give the best care If you provide a complete medical history to us. We specialize in acute and chronic sick care, preventive health and wellness for adults and children. For advanced care and treatment, we will refer to specialists and mental/behavioral health providers as appropriate to provide the best evidence-based care for our patients. Please let us know of all doctors you are seeing and let us help coordinate referrals when possible. Please let us know of changes you or another physician made in your medication regimen.
3. Hospital: Our physicians utilize Baptist, Christus, and Methodist hospitals for inpatient care through coordination with staff hospitalists.
4. Appointment Time: Out of respect for your schedule, we strive to stay on time with our appointments. In order to assist us with this, we ask that you arrive at least 15 minutes prior to your scheduled appointment. Patients arriving 15 minutes past their appointment time will be rescheduled. In order to stay on schedule, multiple problems may need to be addressed in follow-up appointments.
5. Annual Physicals: We emphasize preventive care as a valuable tool for better health. Appointments for physicals will be devoted to preventive services only, any additional problems will need to be addressed at a follow-up visit.
6. Cancellations: We require at least 24 hours in advance when cancelling or rescheduling your appointment. If you fail to cancel or reschedule your appointment, this may be considered a no-show or missed appointment. After 3 missed appointments, we may decide to terminate care. A $30.00 fee will be charged for each NO-SHOW appointment.
7. Refills: We have found that processing refills through your pharmacy is the most efficient and accurate method. We request you contact your pharmacy first, and they will call/fax us with the necessary information to refill your medicine. No refills will be done after hours or on weekends except in cases of a medical emergency (defined as a threat to life, limb, or eyesight). Please allow 3 business days to process refill requests and 5 business days if a prior authorization is needed from your insurance.
8. Payments: All applicable fees, deductibles, coinsurance or copays must be paid at the time of your service. This office will verify your benefits to the best of our ability once you supply your correct insurance information. Verification of coverage does not mean that all services rendered will be covered during your visit; however, and uncovered services may be your responsibility to pay. Outstanding balances must be paid prior to further appointments.
9. Staff Support: Both our physicians and staff are dedicated to your health. Because your physician is not always immediately available, many questions or concerns can be addressed by communication through our staff. If you desire to speak with your physician, it is appropriate to schedule an appointment. Our nurses and medical assistants are extensions of our physicians and serve as valuable resources in delivering timely care, so please treat them with respect. Any discourteous behavior towards our staff will not be tolerated and will result in termination of care.
10. Paperwork: We are happy to complete paperwork/forms related to your health care. Please see paperwork fee schedule.
11. Noncompliance: Your total health is the result of a committed partnership between you and your physician. We reserve the right to discontinue this relationship for noncompliance with health, your health plan, or any of the above policies.
________________________________________ ________________________ Patient Signature Date
PATIENT RIGHTS & RESPONSIBILITIES
1. PATIENT RIGHTS a. ALON Family Health is owned and operated by Rolando Perez, Jr, MD
b. The privacy of all patients shall be respected at all times. Patients shall be treated with respect, consideration,
and dignity.
c. Patients shall receive assistance in a prompt, courteous, and responsible manner.
d. Patient disclosures and medical records are considered confidential. Except as otherwise required by law, patient
records and/or portions of records will not be released to outside entities or individuals without patients’ and/or
designated representatives’ express written approval. Patients are given the opportunity to approve or refuse the
release of their medical records.
e. Patients have the right to know the identity and status of individuals providing services to them.
f. Patients have the right to change providers if they so choose. Patients are informed of the credentials of all staff
who will be providing care during the patients’ stay.
g. Patients, or a legal authorized representative, have the right to thorough, current, and understandable
information regarding their diagnosis, treatment options, prognosis, if known, and follow-up care. All patients will
sign an informed consent form after this information has been provided and their questions answered. When it is
medically inadvisable to give such information to the patient, the information is provided to a person designated
by the patient or to a legally authorized person.
h. Unless participation is medically contraindicated, patients have the right to participate in all decisions involving
their health care.
i. Patients have the right to refuse treatment and to be advised of the alternatives and consequences of their
decisions. Patients are encouraged to discuss their objectives with their providers.
j. Patients have the right to refuse participation in experimental treatment and procedures. Should any
experimental treatment or procedure be considered, it shall be fully explained to the patient prior
to commencement.
k. Patients have the right to make suggestions or express complaints about the care they have received and to
submit such to Rolando Perez, MD who will complete an “Incident Notification” and bring the issue to the
attention of ALON Family Health in a timely manner so the grievance may be addressed.
l. Patients have the right to be provided with information regarding emergency and after-hours care.
m. Patients have the right to obtain a second opinion regarding the recommended procedure. Responsibility for the
expense of the second opinion rests solely with the patient.
n. Patients have the right to a safe and pleasant environment during their care.
o. Patients have the right to an interpreter if required.
p. Patients have the right to be provided informed consent forms as required by the laws of the state of Texas.
q. Patients have the right to truthful marketing and/or advertising regarding the competence and capabilities of the
physicians and staff.
r. Patients have the right to have copies of their Advance Directives and Living Wills in their medical records. In the
event of an emergency, the patient will be transferred to the appropriate facility, which will be notified of such
Advance Directives and/or Living Wills, as defined by state law.
s. Patients will be provided, upon request, all available information regarding services available at the Practice, as
well as information about estimated fees and options for payment.
t. If applicable, patients will be informed of the absence of malpractice insurance coverage.
u. Patients have the right to approve the release of their medical records to other care providers, legal
representatives, and other persons authorized by the patient.
v. Patients have the right to exercise their rights without being subject to discrimination or reprisal.
w. Patients have the right to be free from harassment or abuse.
2. PATIENT RESPONSIBILITIES
a. Patients are expected to provide complete and accurate medical histories, to the best of their ability, including
providing information on all current medications, over-the counter products, dietary supplements, and any
allergies or sensitivities.
b. Patients are responsible for keeping all scheduled appointments and complying with treatment plans to help
ensure appropriate care.
c. Patients are responsible for reviewing and understanding the information provided by their physician or nurse.
Patients are responsible for understanding their insurance coverage and the procedures required to
ensure payment.
d. Patients are responsible for providing insurance information at the time of their visit and for notifying the
receptionist of any changes in information regarding their insurance or medical information.
e. Patients are responsible for paying all charges for copayments, coinsurance and deductibles or for non-covered
services at the time of the visit unless other arrangements have been made in advance with ALON Family Health.
f. Patients are responsible for treating physicians, staff and other patients in a courteous and respectful manner.
g. Patients are responsible for asking questions about their medical care and to seek clarification from their
physician of the services to be provided until they fully understand the care they are to receive.
h. Patients are responsible for following the advice of their provider and to consider the alternatives and/or likely
consequences if they refuse to comply.
i. Patients are responsible for expressing their opinions, concerns, or complaints in a constructive manner to the
appropriate personnel at the Practice.
j. Patients are responsible for notifying their health care providers of patient’s Advance Directives, Living Wills,
Medical Power of Attorney or any other directives that could affect their care. In the event of an emergency, the
patient will be transferred to the appropriate facility. The facility will be notified of the existence of the Advance
Directive, if applicable, and will be provided with a copy.
k. The patient should expect to be provided a copy of the Patient Rights and Responsibilities prior to the date of
a procedure.
QUESTIONS OR CONCERNS?
You and your family should feel you can always voice your concerns. If you share a concern or complaint, your care will not
be affected in any way. The first step is to discuss your concerns with your physician, nurse, or other caregiver. If you have
concerns that are not resolved, please contact ALON Family Health at (210) 534-2566, or [email protected].
Should you continue to remain concerned, you may contact the Texas Medical Board Investigations Department MC-263,
1-800-201-9353, P.O. Box 2018, Austin, TX 78768-2018, or your Ombudsman at
www.cms.hhs.gov/center/ombudsman.asp.
Patient Name: _________________________________________________ Date: _________________________
Patient Signature: _____________________________________________________________________________
INSURANCE BENEFITS AUTHORIZATION AND ASSIGNMENT
I authorize ALON Family Health to release to my insurance company any information required in the course of my examination or treatment. I also authorize any physician, hospital, or clinic to provide details of my history to ALON Family Health.
I hereby assign payment direct to ALON Family Health for medical benefits payable for these services. I understand that I am responsible for payment of all services rendered regardless of insurance coverage.
I accept the terms of this agreement.
Signature: _____________________________________________
Date:___________________
Authorization: Use & Disclosure of Protected Health Information
Effective Date: July 2014
ALON FAMILY HEALTH REQUEST FOR RECORDS
PATIENT INFORMATION: INFORMATION SOURCE (Release from):
Name: Name:
Street: Street:
City: City:
State/Zip: State/Zip:
Telephone: Telephone:
SSN: DOB: FAX:
SEND INFORMATION TO:
ALON Family Health 11503 N.W. Military Hwy, Suite 111, San Antonio, TX 78231
Phone: (210) 534-2566 FAX: (210) 510-2914
Information To Be Released – Covering the Periods of Health Care
From (date) ______________________________________ to (date) _________________________________________ Please check type of information to be released:
Complete health record Operative report and pathology Discharge summary
History and physical exam Consultation reports Progress notes
Laboratory test results X-ray reports X-ray films / images
Photographs, videotapes Complete billing record Itemized bill
Abstract of health record (all typed physician reports and test results)
Other, (specify) _________________________________________________________________________________
Purpose of Request
Treatment or consultation At the request of the patient Billing or claims payment
Other (specify) _________________________________________________________________________________
DDrruugg aanndd//oorr AAllccoohhooll AAbbuussee,, aanndd//oorr PPssyycchhiiaattrriicc,, aanndd//oorr HHIIVV//AAIIDDSS RReeccoorrddss RReelleeaassee I authorize the information source to release my medical or billing records containing information in reference to Drug and/or Alcohol Abuse and treatment: Initial One: Yes_____ No_____ Not Applicable _________
I authorize the information source to release my medical or billing records containing information in reference to Mental Health or Psychiatric treatment: Initial One: Yes_____ No_____ Not Applicable _________
I authorize the information source to release my medical or billing records containing information in reference to HIV/AIDS (Acquired Immunodeficiency Syndrome) testing and/or treatment: Initial One: Yes _____No ____ N/A______
Time Limit & Right to Revoke Authorization Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to the Record Custodian at the requesting ALON Family Health. Unless revoked, this authorization will expire on the following date or event __________________________________________________________________or 180 days from the date of signature.
Re-disclosure I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient or Personal Representative Who May Request Disclosure I understand that I do not have to sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can inspect or copy the protected health information to be used or disclosed. I authorize the information source to release the protected health information specified above.
Signature: ____________________________________________________________ Date: _________________________________
Authority to Sign if not patient: _________________________________________________________________________________
Identity of Requestor Verified via: Photo ID Matching Signature Other, specify _______________________________
Verified by: _________________________________________________________
PEDIATRIC HEALTH HISTORY Place a for all that apply to your child / Marque donde se indica para su niño/a
Name/Nombre:____________________________________________
Date/Fecha:______________________________________________
Age/Edad:____________
Preferred Language/ Idioma preferida_________________________
Prefered language/Idioma preferido:___________________________
AGE:__________
Preferred Language:______________________
Religion:________________________________
ALLERGIES/ALERGIAS : NONE/NINGUNA 1._______________________reaction/reacción ___________________ 2._______________________ reaction /reacción __________________ 3._______________________ reaction/reacción __________________ 4._______________________reaction /reacción __________________
MEDS/MEDICAMENTOS: NONE/NINGUNO
Include over the counter meds and herbal supplements /Incluir medicamentos y suplementos herbals sin receta. Med/Medicamento (mg) Directions/Instrucciones de uso 1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________
4.__________________________________________________________
5.__________________________________________________________
6.__________________________________________________________
7._________________________________________________________
8.__________________________________________________________
9.__________________________________________________________
10._________________________________________________________
11.________________________________________________________
MEDICAL HISTORY/HISTORIAL MEDICO NONE/NINGUNO
Sinus Allergies/Alergias Nasales Kidney disease/Enfermedad de riñón Anxiety or Mood Problems / Liver disease/Enfermedad de higado
Ansiedad o Problemas dl Estado de Animo Migraines/Migrañas AIDS or HIV/SIDA o VIH Osteoporosis Arthritis/Artiritis Seizures/Convulciones Cerebrales Asthma/Asma Sleep apnea/Apnea del Sueño COPD or emphysema/Enfisema Stroke/Infarto Cerebral Diabetes Thyroid disease/Enfermedad de tiroides GERD or Gastritis/Gastritis o Acidez ADHD/Déficit de Atención o Hiperactividad Fibromyalgia/Fibromialgia Cancer/Type ____________________ Heart Attack /Ataque al corazón Cáncer/Tipo _____________________ Heart Disease/Enfermedad Cardiaca Other/Otro _____________________ High Blood Pressure/Presión Alta _________________________________ High Cholesterol/Alto Colesterol _________________________________
SOCIAL HISTORY/HISTORIAL SOCIAL Occupation/Ocupación:______________________________________________________ Education/ Educacion:_______________________________________________________ Smoking/Fuma: NO ______ YES/Si ______ How much? /¿Cuánto? _________________ Alcohol: NO ______ YES/Si ______ How much? /¿Cuánto? _______________________ Illegal Drugs/ Drogas Ilegales: NO ______ YES/Si ______ Which?/¿Cúal? ____________ Any psychological, emotional, physical, or sexual abuse? ¿Algún abuso sexual, psicológico, emocional o físico? NO ______ YES/Si ______ Do you live alone?/ ¿Vive solo? NO ______ YES/Si ______ Who helps you with your medications?/¿Quién le ayuda con los medicamentos? __________________________________________________________________________
FAMILY HISTORY/HISTORIA FAMILIAR NONE/NINGUNA Who?/ ¿Quién? Sinus Alergies/Alergias Nasales ___________________________________ Anxiety or Mood Problems/ Ansiedad o Problemas de Estado de Animo
___________________________________ AIDS or HIV/SIDA o VIH ___________________________________ Arthritis/Artiritis ____________________________________ Asthma/Asma ___________________________________ COPD or emphysema /Enfisema ___________________________________ Diabetes ___________________________________ GERD or Gastritis/Gastritis o Acidez ___________________________________ Fibromyalgia/Fibromialgia ___________________________________ Heart Attack /Ataque al Corazón ___________________________________ Heart Disease/Enfermedad Cardiaca ___________________________________ High Blood Pressure/Presión Alta ___________________________________ High Cholesterol/Alto Colesterol ___________________________________ Kidney disease/Enfermedad de riñón ___________________________________ Liver disease/Enfermedad de higado ___________________________________ Migraines/Migrañas ___________________________________ Osteoporosis ___________________________________ Seizures/Convulciones Cerebrales ___________________________________ Sleep apnea/Apnea del Sueño ___________________________________ Stroke/Infarto Cerebral ___________________________________Sudden Death ___________________________________ Thyroid disease/Enfermedad de tiroides ___________________________________ ADHD/Deficit de Atención o Hiperactividad _________________________________ Cancer /Type ___________________________________
Cáncer/Tipo ___________________________________ Other/Otro ____________________________________________________________
SURGERIES/CIRUGIAS NONE/NINGUNA Year/Año 1.__________________________________________________________ 2._________________________________________________________ 3._________________________________________________________ 4._________________________________________________________
BIRTH HISTORY (Historial de nacimiento)
Where was child born (Donde nacio su niño/a)?_________________ How much did child weigh (cuanto pesó)?______________________ Was your child premature (fue su niño/a prematuro/a)? __________ If yes, how many months (Si?, de cuantos meses)? _______________ Were there any problems after birth (tuvo algún problema después de nacer)? _________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
All information reviewed by Physician/Date:
Name/Nombre:__________________________________________________ Place a for all that apply to you/ Marque donde se indica para usted
REVIEW OF SYSTEMS/Revisión de Sistemas NONE/NINGUNO
Constitutional: ____ fatigue/cansancio ____night sweats/sudores nocturno ____fever/fiebre ____ weight gain/aumento de peso ____ weight loss/pérdida de peso Cardiac: ____chest pain/dolor de pecho ____palpitations/palpitaciones ____leg swelling/hinchazón en las piernas ____short of breath with exercise/dificultad para respirar con el ejercicio ____short of breath lying flat/dificultad para respirar acostado ENT: ____sinus congestion/congestión nasal ____ frequent sneezing/estornudos frecuentes ____hearing loss/pérdida de audición ____ringing in ears/zumbido en los oídos ____ear pain/dolor de oído ____sore throat/dolor de garganta ____hoarseness/ronquera Endocrine: ____sweating/sudor ____thirsty/mucha sed ____ appetite changes/cambios de apetito ____heat or cold sensitive/Sensitividad al calor o frío ____dry mouth/sequedad de boca ____dry eyes/sequedad de ojos Eyes: ____poor vision/visión pobre ____eye pain/dolor de ojos ____ eye drainage/drenaje del ojo ____red eyes/ojos rojos GI: ____heartburn/acidez de estomago ____constipation/estreñimiento ____diarrhea/diarrea ____bloating/entumecimiento del estomago ____bloody stools/sangre en las heces ____trouble swallowing/problema al tragar ____stomach pain/dolor de estómago Hematology: ____easy bruising/contusión fácil ____easy bleeding/fácil sangrado MSK: ____joint pains/dolores en las articulaciones ____ joint stiffness/ rigidez en las articulaciones ____joint swelling/hinchazón en las articulaciones ____knee pain/dolor de rodilla
____muscle pain/dolor muscular ____back pain/dolor de espalda
Neck: ____neck pain/dolor de cuello ____swollen glands/ganglios inflamados ____lumps/nudos o bultos ____stiffness/rigidez del cuello Neuro: ____numbness or tingling/ entumecimiento u hormigueo ____ weakness/debilidad
____dizziness/mareos ____headaches/dolor de cabeza ____ tremors/temblores ____trouble with speech/problema hablar ____seizures/convulciones cerebrales
Resp: ____frequent cough/toz frecuente ____trouble breathing/dificultad para respirar ____wheezing/ruido o silbido al respirar ____snoring /roncar Skin: ____itching/comezón de piel ____rash/ronchas ____dry skin/piel reseca ____ lumps/nudos o bultos ____hair loss/pérdida de cabello Genitourinary: ____frequent urination/deseo de orinar frecuente ____leaking urine/incontinencia de orina ____burning or pain/ardor o dolor al orinar ____frequent night urination/frecuencia de orina en la noche ____erectile problems/problemas de erecion ____vaginal discharge /flujo vaginal ____vaginal itching/irritation /comezon vaginal ____heavy periods (menses) /periodo pesado ____irregular periods (menses) /periodo iregular Vascular: ____calf pain while walking/dolor en pantorrilla o pierna al caminar
____leg cramps/calambres en la piernas
Psych: ____depression/depreción ____anxiety/ansiedad ____mood swings /cambios de humor ____memory loss/pérdida de memoria OTHER/OTRO________________________________________________________________________________________________________________________
All information reviewed by Physician/Date:
IMMUNIZATION HISTORY (Historial de vacunación): Check all vaccinations your child has received /date OR provide a vaccination record.(Marque todas las vacunaciones que he recibido con la última fecha/año cuando recibió la inyección.o puede presentar el registro) Year/ Año Year/ Año Tetanus/ Tetano _______________ Polio (Poliomielitis) _______________ Pneumonia/ Pulmonia _______________ Varicella/Varicela _______________ Flu (influenza)/ Gripa _______________ Meningitis/Inflamacion de meninges _______________ Zosatavax/El herpes _______________ Measles,Mumps,Rubella/Sarampión/Paperas/Rubéola _______________ Gardasil/HPV _______________
